1. TURN: Surveillance results in more bioterrorism related deaths
Dena M. Bravata, MD, 6/1/2004, Annals of Internal Medicine
Bioterrorism surveillance systems with inadequate sensitivity may fail to detect cases of bioterrorism-related illness, which could result in substantial delays in detection and potentially catastrophic increases in morbidity and mortality. Systems with inadequate specificity may have frequent false alarms, which may result in costly actions by clinicians and public health officials or, perhaps even worse, officials ignoring the system when it reports a suspicious event. Because sensitivity and specificity are related, they must be evaluated simultaneously. However, only 3 reports of 3 systems provided numeric data for both sensitivity and specificity of the system (90, 117, 175). This substantially limits our understanding of the accuracy of existing surveillance systems for bioterrorism-related illness. In addition, because there have been so few cases of bioterrorism-related illness, there are no reference standards against which to compare the surveillance data. This lack of a reference standard complicates the evaluation of the sensitivity and specificity of these systems..
a) Tracking refugees with surveillance to mitigate genocide and conflict, has the opposite effect. The intervention prolongs the warfare and suffering
EDWARD N. LUTTWAK, Senior Fellow at the Center for Strategic and International Studies, “Give War a Chance.” Foreign Affairs, Jul/Aug 1999. Vol. 78, Iss. 4; pg. 36, 9 pgs
THE MOST disinterested of all interventions in war-and the most destructive-are humanitarian relief activities. The largest and most protracted is the United Nations Relief and Works Agency (UNRWA). It was built on the model of its predecessor, the United Nations Relief and Rehabilitation Agency (UNRRA), which operated displacedpersons camps in Europe immediately after World War II. The UNRWA was established immediately after the 1948-49 Arab-Israeli war to feed, shelter, educate, and provide health services for Arab refugees who had fled Israeli zones in the former territory of Palestine. By keeping refugees alive in spartan conditions that encouraged their rapid emigration or local resettlement, the UNRRA's camps in Europe had assuaged postwar resentments and helped disperse revanchist concentrations of national groups. But UNRWA camps in Lebanon, Syria, Jordan, the West Bank, and the Gaza Strip provided on the whole a higher standard of living than most Arab villagers had previously enjoyed, with a more varied diet, organized schooling, superior medical care, and no backbreaking labor in stony fields. They had, therefore, the opposite effect, becoming desirable homes rather than eagerly abandoned transit camps. With the encouragement of several Arab countries, the UNRWA turned escaping civilians into lifelong refugees who gave birth to refugee children, who have in turn had refugee children of their own. During its half-century of operation, the UNRWA has thus perpetuated a Palestinian refugee nation, preserving its resentments in as fresh a condition as they were in 1948 and keeping the first bloom of revanchist emotion intact. By its very existence, the UN RWA dissuades integration into local society and inhibits emigration. The concentration of Palestinians in the camps, moreover, has facilitated the voluntary or forced enlistment of refugee youths by armed organizations that fight both Israel and each other. The UN RWA has contributed to a halfcentury of Arab-Israeli violence and still retards the advent of peace. If each European war had been attended by its own postwar UNRWA, today's Europe would be filled with giant camps for millions of descendants of uprooted Gallo-Romans, abandoned Vandals, defeated Burgundians, and misplaced Visigoths-not to speak of more recent refugee nations such as post-ig45 Sudeten Germans (three million of whom were expelled from Czechoslovakia in 1945). Such a Europe would have remained a mosaic of warring tribes, undigested and unreconciled in their separate feeding camps. It might have assuaged consciences to help each one at each remove, but it would have led to permanent instability and violence. The UNRWA has counterparts elsewhere, such as the Cambodian camps along the Thai border, which incidentally provided safe havens for the mass-murdering Khmer Rouge. But because the United Nations is limited by stingy national contributions, these camps' sabotage of peace is at least localized. That is not true of the proliferating, feverishly competitive nongovernmental organizations (NGOS) that now aid war refugees. Like any other institution, these NGOs are interested in perpetuating themselves, which means that their first priority is to attract charitable contributions by being seen to be active in high-visibility situations. Only the most dramatic natural disasters attract any significant mass-media attention, and then only briefly; soon after an earthquake or flood, the cameras depart. War refugees, by contrast, can win sustained press coverage if kept concentrated in reasonably accessible camps. Regular warfare among well-developed countries is rare and offers few opportunities for such NGOS, so they focus their efforts on aiding refugees in the poorest parts of the world. This ensures that the food, shelter, and health care offered-although abysmal by Western standards-exceeds what is locally available to non-refugees. The consequences are entirely predictable. Among many examples, the huge refugee camps along the Democratic Republic of Congo's border with Rwanda stand out. They sustain a Hutu nation that would otherwise have been dispersed, making the consolidation of Rwanda impossible and providing a base for radicals to launch more Tutsi-killing raids across the border. Humanitarian intervention has worsened the chances of a stable, long-term resolution of the tensions in Rwanda. To keep refugee nations intact and preserve their resentments forever is bad enough, but inserting material aid into ongoing conflicts is even worse. Many NGOS that operate in an odor of sanctity routinely supply active combatants. Defenseless, they cannot exclude armed warriors from their feeding stations, clinics, and shelters. Since refugees are presumptively on the losing side, the warriors among them are usually in retreat. By intervening to help, NGOS systematically impede the progress of their enemies toward a decisive victory that could end the war. Sometimes NGOS, impartial to a fault, even help both sides, thus preventing mutual exhaustion and a resulting settlement. And in some extreme cases, such as Somalia, NGOs even pay protection money to local war bands, which use those funds to buy arms. Those NGos are therefore helping prolong the warfare whose consequences they ostensibly seek to mitigate.
b) Wars must run their natural course without intervention, in order to ultimately resolve political conflicts and lead to peace
EDWARD N. LUTTWAK, Senior Fellow at the Center for Strategic and International Studies, “Give War a Chance.” Foreign Affairs, Jul/Aug 1999. Vol. 78, Iss. 4; pg. 36, 9 pgs
AN UNPLEASANT truth often overlooked is that although war is a great evil, it does have a great virtue: it can resolve political conflicts and lead to peace. This can happen when all belligerents become exhausted or when one wins decisively. Either way the key is that the fighting must continue until a resolution is reached. War brings peace only after passing a culminating phase of violence. Hopes of military success must fade for accommodation to become more attractive than further combat. Since the establishment of the United Nations and the enshrinement of great-power politics in its Security Council, however, wars among lesser powers have rarely been allowed to run their natural course. Instead, they have typically been interrupted early on, before they could burn themselves out and establish the preconditions for a lasting settlement. Cease-fires and armistices have frequently been imposed under the aegis of the Security Council in order to halt fighting. NATO's intervention in the Kosovo crisis follows this pattern. But a cease-fire tends to arrest war-induced exhaustion and lets belligerents reconstitute and rearm their forces. It intensifies and prolongs the struggle once the cease-fire ends-and it does usually end. This was true of the Arab-Israeli war of 1948-49, which might have come to closure in a matter of weeks if two cease-fires ordained by the Security Council had not let the combatants recuperate. It has recently been true in the Balkans. Imposed cease-fires frequently interrupted the fighting between Serbs and Croats in Krajina, between the forces of the rump Yugoslav federation and the Croat army, and between the Serbs, Croats, and Muslims in Bosnia. Each time, the opponents used the pause to recruit, train, and equip additional forces for further combat, prolonging the war and widening the scope of its killing and destruction. Imposed armistices, meanwhile-again, unless followed by negotiated peace accords-artificially freeze conflict and perpetuate a state of war indefinitely by shielding the weaker side from the consequences of refusing to make concessions for peace. The Cold War provided compelling justification for such behavior by the two superpowers, which sometimes collaborated in coercing less-powerful belligerents to avoid being drawn into their conflicts and clashing directly. Although imposed cease-fires ultimately did increase the total quantity of warfare among the lesser powers, and armistices did perpetuate states of war, both outcomes were clearly lesser evils (from a global mrpoint of view) than the possibility of nuclear war. But today, neither Americans nor Russians are inclined to intervene competitively in the wars of lesser powers, so the unfortunate consequences of interrupting war persist while no greater danger is averted. It might be best for all parties to let minor wars burn themselves out.
. TURN-
Open information from disease surveillance are open for chaotic false alarms
There is an unavoidable conflict between freedom of access to information
and the risk of spurious interpretation of this information, leading
in the worst case to a false alert. This is particularly true when searches are made in
units of space or time that are too small, leading to analyses that are
statistically meaningless. The open philosophy of the Internet brings this
problem into the public arena. But do we have any alternative? How do we
decide which of the maps or curves are not suitable for public view?
Information on small numbers of cases is regularly published on many
epidemiological bulletins, and this may be also used spuriously.
We therefore consider that, instead of censoring material, we should train
users of the Internet to ask the appropriate questions of such a database.
We have posted warnings about inappropriate use of information that appear
when any requests for data are made, and users can send email requests for
epidemiological help. We also maintain a weekly updated electronic report,
written by epidemiologists in simple words, to guide users in their interactive
queries on the most recent data. Moreover, the site provides links to other
expert information classified by topics (such influenza, diarrhoea) or by
organisations (such WHO, CDSC). Thus, users have the opportunity to extend
their expertise by comparing our data with those of other sources.
We thank the sentinel general practitioners who collected these data. The
Sentinel system was developed at INSERM (national institute of health and
medical research) U.444 in collaboration with the Reseau National de Sante
Publique (public health network) and the Direction Generale de la Sante
(national department of health).
Quarentines increase the spread of diseases by grouping healthy and not-healthy people together, as well as insinuate backlash from citizens
Joseph Barbera, MD, Insitute for Crisis and Disease Management, Anthony Macintyre, MD Department of Emergency Medicine in George Washington University Medical Center, and Larry Gostin, JD, PhD, center for the Law and Public’s Health. Dec 5, 2001. JAMA, Vol. 286, No.21.
As noted herein, there are US historical examples in which persons with clear evidence of infection with a contagious disease have been quarantined together with persons with no evidence of infection.48-49 It is now beyond dispute that such measures would be unethical today, but a recent event illustrates that this ethical principle might still be disregarded or misunderstood.55 A passenger returning to the United States was noted to be ill and vomiting on an airline flight, and the passenger's consequent subconjunctival hemorrhages were initially mistaken to be a sign of a coagulopathic infection. On arrival at a major US airport, the plane was diverted and quarantined by airport authorities with all passengers on board, including the potential index case. They were released after an hour-long period of investigation, when public health authorities arrived and concluded that there was no dangerous contagion. Had this been an actual contagious disease, quarantined passengers may have been subjected to an increased risk by continued confinement on the parked aircraft with the ill person. At a minimum, passengers should have been allowed to disembark and remain in an area separate from the index case while this person was being evaluated. What Are the Consequences if the Public Declines to Obey Quarantine Orders? It is not clear how those quarantined would react to being subjected to compulsory confinement. Civilian noncompliance with these public health efforts could compromise the action and even become violent. Historical quarantine incidents have generated organized civil disobedience and wholesale disregard for authority. Such conditions led to riots in Montreal, Quebec, during a smallpox epidemic in 1885.24(pp285-286) Some might lose confidence in government authorities and stop complying with other advised public health actions (eg, vaccination, antibiotic treatment) as well. The possibility also exists for development of civilian vigilantism to enforce quarantine, as occurred in New York City in 1892.48 The rules of engagement that police are expected to follow in enforcing quarantine must be explicitly determined and communicated in advance. Protection of police personnel and their families against infection would be essential to police cooperation.
Dena M. Bravata, MD, 6/1/2004, Annals of Internal Medicine
Bioterrorism surveillance systems with inadequate sensitivity may fail to detect cases of bioterrorism-related illness, which could result in substantial delays in detection and potentially catastrophic increases in morbidity and mortality. Systems with inadequate specificity may have frequent false alarms, which may result in costly actions by clinicians and public health officials or, perhaps even worse, officials ignoring the system when it reports a suspicious event. Because sensitivity and specificity are related, they must be evaluated simultaneously. However, only 3 reports of 3 systems provided numeric data for both sensitivity and specificity of the system (90, 117, 175). This substantially limits our understanding of the accuracy of existing surveillance systems for bioterrorism-related illness. In addition, because there have been so few cases of bioterrorism-related illness, there are no reference standards against which to compare the surveillance data. This lack of a reference standard complicates the evaluation of the sensitivity and specificity of these systems..
a) Tracking refugees with surveillance to mitigate genocide and conflict, has the opposite effect. The intervention prolongs the warfare and suffering
EDWARD N. LUTTWAK, Senior Fellow at the Center for Strategic and International Studies, “Give War a Chance.” Foreign Affairs, Jul/Aug 1999. Vol. 78, Iss. 4; pg. 36, 9 pgs
THE MOST disinterested of all interventions in war-and the most destructive-are humanitarian relief activities. The largest and most protracted is the United Nations Relief and Works Agency (UNRWA). It was built on the model of its predecessor, the United Nations Relief and Rehabilitation Agency (UNRRA), which operated displacedpersons camps in Europe immediately after World War II. The UNRWA was established immediately after the 1948-49 Arab-Israeli war to feed, shelter, educate, and provide health services for Arab refugees who had fled Israeli zones in the former territory of Palestine. By keeping refugees alive in spartan conditions that encouraged their rapid emigration or local resettlement, the UNRRA's camps in Europe had assuaged postwar resentments and helped disperse revanchist concentrations of national groups. But UNRWA camps in Lebanon, Syria, Jordan, the West Bank, and the Gaza Strip provided on the whole a higher standard of living than most Arab villagers had previously enjoyed, with a more varied diet, organized schooling, superior medical care, and no backbreaking labor in stony fields. They had, therefore, the opposite effect, becoming desirable homes rather than eagerly abandoned transit camps. With the encouragement of several Arab countries, the UNRWA turned escaping civilians into lifelong refugees who gave birth to refugee children, who have in turn had refugee children of their own. During its half-century of operation, the UNRWA has thus perpetuated a Palestinian refugee nation, preserving its resentments in as fresh a condition as they were in 1948 and keeping the first bloom of revanchist emotion intact. By its very existence, the UN RWA dissuades integration into local society and inhibits emigration. The concentration of Palestinians in the camps, moreover, has facilitated the voluntary or forced enlistment of refugee youths by armed organizations that fight both Israel and each other. The UN RWA has contributed to a halfcentury of Arab-Israeli violence and still retards the advent of peace. If each European war had been attended by its own postwar UNRWA, today's Europe would be filled with giant camps for millions of descendants of uprooted Gallo-Romans, abandoned Vandals, defeated Burgundians, and misplaced Visigoths-not to speak of more recent refugee nations such as post-ig45 Sudeten Germans (three million of whom were expelled from Czechoslovakia in 1945). Such a Europe would have remained a mosaic of warring tribes, undigested and unreconciled in their separate feeding camps. It might have assuaged consciences to help each one at each remove, but it would have led to permanent instability and violence. The UNRWA has counterparts elsewhere, such as the Cambodian camps along the Thai border, which incidentally provided safe havens for the mass-murdering Khmer Rouge. But because the United Nations is limited by stingy national contributions, these camps' sabotage of peace is at least localized. That is not true of the proliferating, feverishly competitive nongovernmental organizations (NGOS) that now aid war refugees. Like any other institution, these NGOs are interested in perpetuating themselves, which means that their first priority is to attract charitable contributions by being seen to be active in high-visibility situations. Only the most dramatic natural disasters attract any significant mass-media attention, and then only briefly; soon after an earthquake or flood, the cameras depart. War refugees, by contrast, can win sustained press coverage if kept concentrated in reasonably accessible camps. Regular warfare among well-developed countries is rare and offers few opportunities for such NGOS, so they focus their efforts on aiding refugees in the poorest parts of the world. This ensures that the food, shelter, and health care offered-although abysmal by Western standards-exceeds what is locally available to non-refugees. The consequences are entirely predictable. Among many examples, the huge refugee camps along the Democratic Republic of Congo's border with Rwanda stand out. They sustain a Hutu nation that would otherwise have been dispersed, making the consolidation of Rwanda impossible and providing a base for radicals to launch more Tutsi-killing raids across the border. Humanitarian intervention has worsened the chances of a stable, long-term resolution of the tensions in Rwanda. To keep refugee nations intact and preserve their resentments forever is bad enough, but inserting material aid into ongoing conflicts is even worse. Many NGOS that operate in an odor of sanctity routinely supply active combatants. Defenseless, they cannot exclude armed warriors from their feeding stations, clinics, and shelters. Since refugees are presumptively on the losing side, the warriors among them are usually in retreat. By intervening to help, NGOS systematically impede the progress of their enemies toward a decisive victory that could end the war. Sometimes NGOS, impartial to a fault, even help both sides, thus preventing mutual exhaustion and a resulting settlement. And in some extreme cases, such as Somalia, NGOs even pay protection money to local war bands, which use those funds to buy arms. Those NGos are therefore helping prolong the warfare whose consequences they ostensibly seek to mitigate.
b) Wars must run their natural course without intervention, in order to ultimately resolve political conflicts and lead to peace
EDWARD N. LUTTWAK, Senior Fellow at the Center for Strategic and International Studies, “Give War a Chance.” Foreign Affairs, Jul/Aug 1999. Vol. 78, Iss. 4; pg. 36, 9 pgs
AN UNPLEASANT truth often overlooked is that although war is a great evil, it does have a great virtue: it can resolve political conflicts and lead to peace. This can happen when all belligerents become exhausted or when one wins decisively. Either way the key is that the fighting must continue until a resolution is reached. War brings peace only after passing a culminating phase of violence. Hopes of military success must fade for accommodation to become more attractive than further combat. Since the establishment of the United Nations and the enshrinement of great-power politics in its Security Council, however, wars among lesser powers have rarely been allowed to run their natural course. Instead, they have typically been interrupted early on, before they could burn themselves out and establish the preconditions for a lasting settlement. Cease-fires and armistices have frequently been imposed under the aegis of the Security Council in order to halt fighting. NATO's intervention in the Kosovo crisis follows this pattern. But a cease-fire tends to arrest war-induced exhaustion and lets belligerents reconstitute and rearm their forces. It intensifies and prolongs the struggle once the cease-fire ends-and it does usually end. This was true of the Arab-Israeli war of 1948-49, which might have come to closure in a matter of weeks if two cease-fires ordained by the Security Council had not let the combatants recuperate. It has recently been true in the Balkans. Imposed cease-fires frequently interrupted the fighting between Serbs and Croats in Krajina, between the forces of the rump Yugoslav federation and the Croat army, and between the Serbs, Croats, and Muslims in Bosnia. Each time, the opponents used the pause to recruit, train, and equip additional forces for further combat, prolonging the war and widening the scope of its killing and destruction. Imposed armistices, meanwhile-again, unless followed by negotiated peace accords-artificially freeze conflict and perpetuate a state of war indefinitely by shielding the weaker side from the consequences of refusing to make concessions for peace. The Cold War provided compelling justification for such behavior by the two superpowers, which sometimes collaborated in coercing less-powerful belligerents to avoid being drawn into their conflicts and clashing directly. Although imposed cease-fires ultimately did increase the total quantity of warfare among the lesser powers, and armistices did perpetuate states of war, both outcomes were clearly lesser evils (from a global mrpoint of view) than the possibility of nuclear war. But today, neither Americans nor Russians are inclined to intervene competitively in the wars of lesser powers, so the unfortunate consequences of interrupting war persist while no greater danger is averted. It might be best for all parties to let minor wars burn themselves out.
. TURN-
Open information from disease surveillance are open for chaotic false alarms
Boussard, computer scientist, 11/30, 1996
"Sentiweb: French communicable disease surveillance on the
world wide web" [Google]
http://www.bmj.com/cgi/content/full/313/7069/1381?ck=nck [Hao]
There is an unavoidable conflict between freedom of access to information
and the risk of spurious interpretation of this information, leading
in the worst case to a false alert. This is particularly true when searches are made in
units of space or time that are too small, leading to analyses that are
statistically meaningless. The open philosophy of the Internet brings this
problem into the public arena. But do we have any alternative? How do we
decide which of the maps or curves are not suitable for public view?
Information on small numbers of cases is regularly published on many
epidemiological bulletins, and this may be also used spuriously.
We therefore consider that, instead of censoring material, we should train
users of the Internet to ask the appropriate questions of such a database.
We have posted warnings about inappropriate use of information that appear
when any requests for data are made, and users can send email requests for
epidemiological help. We also maintain a weekly updated electronic report,
written by epidemiologists in simple words, to guide users in their interactive
queries on the most recent data. Moreover, the site provides links to other
expert information classified by topics (such influenza, diarrhoea) or by
organisations (such WHO, CDSC). Thus, users have the opportunity to extend
their expertise by comparing our data with those of other sources.
We thank the sentinel general practitioners who collected these data. The
Sentinel system was developed at INSERM (national institute of health and
medical research) U.444 in collaboration with the Reseau National de Sante
Publique (public health network) and the Direction Generale de la Sante
(national department of health).
Quarentines increase the spread of diseases by grouping healthy and not-healthy people together, as well as insinuate backlash from citizens
Joseph Barbera, MD, Insitute for Crisis and Disease Management, Anthony Macintyre, MD Department of Emergency Medicine in George Washington University Medical Center, and Larry Gostin, JD, PhD, center for the Law and Public’s Health. Dec 5, 2001. JAMA, Vol. 286, No.21.
As noted herein, there are US historical examples in which persons with clear evidence of infection with a contagious disease have been quarantined together with persons with no evidence of infection.48-49 It is now beyond dispute that such measures would be unethical today, but a recent event illustrates that this ethical principle might still be disregarded or misunderstood.55 A passenger returning to the United States was noted to be ill and vomiting on an airline flight, and the passenger's consequent subconjunctival hemorrhages were initially mistaken to be a sign of a coagulopathic infection. On arrival at a major US airport, the plane was diverted and quarantined by airport authorities with all passengers on board, including the potential index case. They were released after an hour-long period of investigation, when public health authorities arrived and concluded that there was no dangerous contagion. Had this been an actual contagious disease, quarantined passengers may have been subjected to an increased risk by continued confinement on the parked aircraft with the ill person. At a minimum, passengers should have been allowed to disembark and remain in an area separate from the index case while this person was being evaluated. What Are the Consequences if the Public Declines to Obey Quarantine Orders? It is not clear how those quarantined would react to being subjected to compulsory confinement. Civilian noncompliance with these public health efforts could compromise the action and even become violent. Historical quarantine incidents have generated organized civil disobedience and wholesale disregard for authority. Such conditions led to riots in Montreal, Quebec, during a smallpox epidemic in 1885.24(pp285-286) Some might lose confidence in government authorities and stop complying with other advised public health actions (eg, vaccination, antibiotic treatment) as well. The possibility also exists for development of civilian vigilantism to enforce quarantine, as occurred in New York City in 1892.48 The rules of engagement that police are expected to follow in enforcing quarantine must be explicitly determined and communicated in advance. Protection of police personnel and their families against infection would be essential to police cooperation.